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Identifying Nursing practices
that facilitate the Mother-Premature Baby bond
in the Neonatal Care Unit (NICU)
Patience Ayisibea and Sarah Kwakyewaa-Bosompem
Degree Thesis
Degree Programme in Nursing
2020
DEGREE THESIS
Arcada
Degree Programme: Nursing
Identification number: 20786 & 20809
Author: Patience Ayisibea and Sarah Kwakyewaa-Bosompem
Title: Identifying nursing practices that facilitate Mother-Prema-
ture Baby Bond in the Neonatal Intensive Care Unit (NICU)
Supervisor (Arcada): Pamela Gray
Commissioned by:
The existence of a strong loving bond between a newly born infant and their mother is
essential for the social, cognitive, and emotional development of the infant. Mothers who
give birth to premature babies often have their babies separated from them as they receive
specialized treatment at the NICU. This separation stops opportunities for mother-infant
bonding and places mothers in psychological distress and uncertainty in which nurses play
a vital role in the NICU and possess the ability to facilitate mother-infant bonding at the
NICU. The aim of this study is to identify the nursing care practices and interventions that
nurses can adopt to facilitate and support the bonding of mothers and their premature in-
fants at the NICU and to help answer, what are the nursing care practices and interventions
that nurses can adopt to facilitate the bonding of mothers and their premature infants at the
Neonatal In-tensive Care Unit (NICU)?
The Theory of Human Caring by Dr Jean Watson is used as the theoretical framework and
the study is a descriptive literature review which utilised inductive thematic analysis.
The findings revealed common themes that were found and summarized into two major
themes and then divided into subthemes. The findings revealed that nurses can promote the
mother-infant interaction and mother-nurse interaction to facilitate the bond between the
mother-premature infant. The promotion of mother-infant interaction provides opportuni-
ties for physical contact, provides opportunities for remote monitoring, and opportunities
for mothers’ participation in routine care. The mother-nurse interaction shows nurses need
to communicate consistently, offer assurance, empathetic treatment, and exhibit trustwor-
thiness to the parents at the NICU. The study finally points that, the NICU nurse possesses
the power to either promote or hinder the bonding process. Because there is evidence that
early mother-infant bonding is essential for an infant’s neurological development process,
nurses should take the role of facilitating the attachment process from birth seriously.
Keywords: Premature birth, NICU, Bonding, Nursing Care Practices,
Mother-Infant
Number of pages: 54
Language: English
Date of acceptance: 9.11.2020
CONTENTS
1 Introduction .......................................................................................................... 7
2 Background .......................................................................................................... 9
2.1 Premature birth .......................................................................................................... 9
2.2 Neonatal Intensive Care Unit (NICU) ........................................................................ 11
2.3 Bonding ................................................................................................................... 11
3 Theoritical framework ........................................................................................ 15
3.1 Watsons Theory of Human Caring ........................................................................... 15
3.2 Implication of the Watsons Theory of Human Caring to the Study. ............................ 17
4 Aims And Research Question ........................................................................... 19
5 Methodology ...................................................................................................... 20
5.1 Data collection ......................................................................................................... 20
5.2 Data Analysis........................................................................................................... 21
5.3 Ethical consideration ................................................................................................ 22
6 Results ............................................................................................................... 24
6.1 Promotion of Mother-Infant Interaction ..................................................................... 24
6.1.1 Providing opportunities for physical contact ...................................................... 24
6.1.2 Providing opportunities for remote monitoring ................................................... 25
6.1.3 Providing opportunities for the participation in routine care ............................... 26
6.2 Mother-Nurse Interaction ......................................................................................... 27
6.2.1 Communication ................................................................................................ 27
6.2.2 Assurance ........................................................................................................ 28
6.2.3 Empathic treatment .......................................................................................... 29
6.2.4 Exhibition of trustworthiness ............................................................................. 29
7 Discussion ......................................................................................................... 30
7.1 Discussion in relation to the literature ....................................................................... 30
7.2 Discussion in relation to Watson Theory of Human Caring ....................................... 33
8 Conclusion ......................................................................................................... 35
8.1 Strengths and limitations .......................................................................................... 35
8.2 Recommendations for future studies ........................................................................ 36
References ................................................................................................................ 37
Appendix 1 Characteristics of the articles reviewed .............................................. 46
Figures
Figure 1. Watson's Carative Nursing Practices (Watson 2011b)................................... 17
Tables
Table 1. Themes and Sub-themes of Nursing Interventions that Promote Maternal -Infant
Bonding at the NICU. ................................................................................................. 22
FOREWORD
We would like to take this opportunity to thank the Almighty God for his great protection
and thank Arcada University of Applied Sciences for offering us the opportunity to study
and accomplish our Degree Programme in Nursing.
We would like to also extend our sincere gratitude to Pamela Gray for her generous guid-
ance during our thesis supervision, advice, patience, and support during our studies. Sin-
cerely, it would not have been possible for us to complete this thesis without her effort.
Additionally, Patience Ayisibea would like to personally acknowledge some special peo-
ple in her life. First, I thank my Auntie Mrs. Henrietta Awuah Addae and her family for
their contribution in my life. Secondly, I like to thank Mr. Asafo-Adjei Agyenim Boateng,
Rev. Dr, Seree Yeboah Mensah, and family, Pirjo Tuominen and her husband Raimo
Tuominen for their great support and direction in diverse ways and my final gratitude
goes to my family, especially my two lovely sons Jaden and Aiden and the Hayes family
for their immerse support. I am blessed and lucky to have you all in my life, for without
them, I could not have done it.
Finally, Sarah Kwakyewaa-Bosompem would like to express her appreciation to her
lovely husband Mr. George Dosu and our two lovely children Daniel and Dorinda who
encouraged, supported, and accompanied me through hard times. Madam Elizabeth
Frimpong and Manuela Frimpong for their special help rendered when needed. Mr &
Mrs. Ernest Kenah-Amoah for their support and contribution during my studies. I would
like to also thank my relatives especially Miss Agartha Hagan for her immerse contribu-
tion into my life.
ACRONYMS NICU Neonatal Intensive Care Unit
KMC Kangaroo mother care
FCC Family-centred care
7
1 INTRODUCTION
There is usually a great dependence of human babies on their parents on birth. It is this
characteristic of newly born babies that necessitates great care and bonding early in their
lives. When there is existence of a strong attachment or a loving bond between a newly
born infant and their primary caregiver, usually their parent, the newly born undergoes
optimum social, cognitive, and emotional development (Winston and Chicot, 2016).
Bonding between mother and child is therefore very crucial in the early development of
the child and caregivers including nurses should try to ensure this bond and mother-child
attachment is nurtured. When this is done right from infancy, babies are positioned to
grow and become independent, happy, and resilient adults.
Some children are lucky to have incidence free early lives but some due to complications
at birth, illness after birth or a combination of other factors must spend their early lives
in the Neonatal Intensive Care Unit (NICU). According to World Health Organisation
(2020) statistics, about 10% of all births worldwide are preterm. This occurrence endan-
gers the chance that many mothers and their children must make strong early attachments.
In the NICU, the child is separated from his/her mother. This prevents effective bonding
as it necessitates that the mother and his/her new-born baby be close to each other so that
a nurturing connection between them can be established (Flacking et al., 2012). The
mother-infant separation at the NICU may interrupt the mother-infant bonding process
due to the separation it causes. It may also be a significant cause of emotional distress to
infants’ mothers and families which may affect future bonding opportunities (Ionio et al.,
2019).
Therefore, it is during this period of emotional, psychological, and physiological trauma
upon mothers together with their premature babies in the Intensive Care Unit that nursing
care becomes very much necessary and needed more than ever before. In recent years,
especially, after the recognition of the importance of early bonding to a premature child’s
development; there has been an emphasis on ensuring that nursing care practices in the
NICU promote mother-premature baby bonding. As NICU admission greatly reduces the
mother-premature infant relationship and bonding, there is a need to identify nursing
8
practices that nurses can adopt at the NICU to facilitate greater bonding be-tween a
mother and her preterm infant.
The introduction chapter explains the general background of the study, the purpose, and
the motivation behind this study. The background chapter deals with preterm birth and
bonding between mothers and preterm infants at the NICU. The theoretical framework
explains the chosen nursing theory used in this study. The aims and research question
were used to investigate the study and the methodology chapter explore the method, data
collection, data analysis used in this study. The results and the discussion chapters present
findings from the analysed data of the literature reviews and discusses the findings in
relation to the articles and the theoretical framework. The final chapter concludes and
discusses the strengths and limitations of the study and suggests recommendations for
future research.
9
2 BACKGROUND
There has been great interest in the field of paediatrics medicine and nursing on how
mother-premature baby bonding can be established and sustained at the Neonatal Inten-
sive Care Unit (NICU). Often, the experiences of mothers whose infants are admitted to
the Neonatal Intensive Care Unit is usually traumatic. Mothers have been found to expe-
rience significant psychological distress, loss of a chance to discharge their parental role
and disruptions of mother infant bonding. Formation of enduring mother-premature infant
bonding is an essential feature of any human experience. The bonding process be-tween
mother and infant begins before birth and continues even after the child is born (Wigert,
Johansson, Berg and Hellstrom, 2006). Past research has indicated that bonding is a cru-
cial developmental force in the life of any individual and its absence can lead the child to
experience social incompetence and cognitive disability in later life (Winston and Chicot,
2016). It is for this reason that promoting mother-infant is a crucial aspect of care provi-
sion. Parents need the requisite support if they are to form enduring bonds with their
premature infants. Mother-premature infant bonding is a crucial step in the cognitive and
physical development of the child and begins during pregnancy and continues after child-
birth (Wigert, Johansson, Berg and Hellstrom, 2006). The NICU environment can disrupt
the all-important attachment process and affect the effective bonding between mother and
their infant placing the child at a risk of the neurobiological complications later in life
(Schmücker et al., 2005). With nurses playing an especially important role in the NICU,
it is essential that they recognize the nursing care practices and interventions to facilitate
the bond between mother and the premature infant.
2.1 Premature birth
According to Quinn et al. (2016) premature birth can be described as the birth of baby
more than three weeks before the due date. Premature birth, this author notes is a situation
where babies are born before 37 weeks of pregnancy instead of a full-term pregnancy-cy
which is normally 40 weeks. As a result, babies born preterm weigh much less than full-
term as babies spend minimal amount of time to develop in the womb. There are different
categories of preterm babies characterized by how soon the baby is born. According to
Quinn et al. (2016), there are several classes of preterm infants which include 1) late
10
preterm, when the baby is born between 34 and 36 weeks of pregnancy, 2) moderately
preterm, when the infant is born between 32 and 34 weeks of pregnancy, 3) very preterm,
when the baby is born at less than 32 weeks of pregnancy and 4) extremely pre-term, thus
when the baby is born before 25 weeks of pregnancy.
A lot of complexity on the causes of preterm births exist and the pathophysiologic triggers
that cause preterm births are largely unknown. Several underlying factors that pre-dispose
mothers to experience pre-mature births have however been identified. Some physiolog-
ical and mechanical factors that have been found to increase the risk of pre-term births
include antepartum haemorrhage, cervical incompetence, uterine over-distention, hormo-
nal changes as well as inflammation and bacterial infection (Simmons, Rubens, Darm-
stadt and Gravett, 2010; Villar et al., 2012). Others such as multiple births, being over-
weight or underweight pre-pregnancy, existence of physical and psychosocial stress as
well as maternal age (over 35 years and under 17 years) have also been associated with
increased risk of pre-term births (Simmons, Rubens, Darmstadt and Gravett, 2010).
.
Premature babies, especially those born earliest, in most cases are characterized by med-
ical complications and are often admitted into the NICU for specialized treatment and
care. While the NICU is a key hub for pre-term infants’ care, it is often a complex, highly
structured environment that has been reported to impede meaningful interactions be-
tween mother and child (Hopwood, 2010). Disruption of the all-important attachment
process and effective bonding between mother and child have reportedly been caused by
parent child separation, maternal anxiety as well as the neurobiological risk that the child
experiences while in isolation in the NICU (Schmücker et al., 2005). The effects of child’s
care at the NICU as regards to mother infant bonding in the NICU is worrying. This is
because about 10% of all births worldwide are preterm according to the World Health
Organization (World Health Organisation, 2020). As NICU admission greatly reduces the
mother-infant relationship and bonding, there is a need to identify ways that nurses at the
NICU can facilitate greater bonding between a mother and her young infant.
11
2.2 Neonatal Intensive Care Unit (NICU)
The Neonatal Intensive Care Unit (NICU) is usually a specialized treatment setting for
premature infants who are deemed high-risk. It is a technological unit which plays an
important role of keeping infants alive and giving them a chance at life. Its environment
is however intimidating to parents whose infants need specialized care. First, mothers at
the NICU suffer significant psychological distress. Their helplessness in protecting their
baby from medical procedures, guilt from failing to birth a healthy child, exposure to
near-death infant resuscitation events, and inability to interact and provide care to their
children works to exacerbate this psychological distress. Ultimately, mothers become
emotionally unavailable to bond with their children (Lindberg and Öhrling, 2008). Sec-
ondly, the mother-child separation that is necessary for infants to be provided with spe-
cialised care may result in delayed maternal attachment (Obeidat, Bond and Callister,
2009). This early separation strains infant-mother relationship as mothers need to hold,
see, and touch their new-born if they are to facilitate this early attachment and bonding
(Hall, 2005). Noting the significance of bonding and the challenges that mothers face in
their attempt to initiate and establish this early attachment with their new-born babies, it
is very important that strategies are developed to enhance mother infant bonding at the
NICU.
2.3 Bonding
Shroff (2016) defines bonding as the special attachment that forms between a mother and
father and their new baby; and it is that bond which sends them into their new-born room
in the middle of the night at the slightest grumble with urgency. It is also what makes
parents want to instinctively care for and nurture their child (Hill and Flanagan, 2019).
Also, bonding could occur for merely looking at the new-born, through touching of the
skin, feeding, and caring. In addition, rocking the baby to sleep or stroking the back might
establish the new relationship and make them feel more comfortable.
According to Vedova, Dabrassi and Imbasciati (2008), the significance of a parents’ af-
fection towards an unborn baby has been previously discussed as a continuous interactive
conscious or unconsciousness field. The process of establishing maternal personality is
12
tangled with the developing an emotional attachment with the unborn child. Bowlby
(1988) referred to this emotional tie as ‘prenatal attachment’. According to Bowlby
(1988), attachment or bonding is the emotional tie that the baby forms between himself
and those who care for it. This attachment according to Bowlby ensures the survival of
the baby, which is therefore grounded on the activity of neural paths in the baby and in
the adult’s mind. Consequently, the baby develops an internal representation of the self,
of others and of relationships in general due to the initial attachment experiences. These
early representations, ‘internal working models’, influence the formation of attachment
relationships for the rest of the individual’s life. That baby enjoying nurturing and safe
relationship with those who care for it enhances a secure personal basis and therefore a
sense of trust in others. This bond is characterized by emotions such as affection and trust.
And any two people who spend time together may form a bond (Barker, Daniels, O’Neal
and Sell, 2017).
The study of mother-premature baby bonding has gained such prevalence not only be-
cause of its being very essential for the baby’s sense of security, self-esteem and cognitive
development but also because in the case of the parents, it serves as a conduit for con-
necting them to their latest and important arrival. Normally, bonding starts even be-fore
the baby is born such as during the first little flutters in the belly occurs or when seeing
the baby kick on the ultra-sound screen (Feldman et al., 1999). Early mother-infant con-
tact also significantly promotes bonding and the affectionate behaviour that both mother
and infant give to each other (Anisfeld and Lipper, 1983). Despite the importance of ef-
fective and smooth mother-child bonding, some situations that some mothers find them-
selves in makes it difficult for the establishment of a solid mother-child bond. For in-
stance, some mothers develop postpartum depression after birth. This condition that ap-
pears six weeks after delivery in mothers is characterized by episodes of behavioural and
mental disorders has been known to persist for up to a year (American Psychiatric Asso-
ciation, 2013). It has also been known to occur in 10-15% of all new mothers (Anokye et
al., 2018). This condition negatively affects the mother’s social and occupational func-
tioning as well as the child’s health (Corrigan, Kwasky and Groh, 2015). Ultimately this
may prevent the mother and child from completely bonding.
13
Difficult pregnancies and child delivery may also contribute to insufficient bonding be-
tween mother and child. Child delivery is usually a very painful process that women ex-
perience and to some delivery is usually riddled by life threatening complications. Most
difficult child deliveries necessitate painful procedures such as the c-section and are also
characterized by exhaustion, pain, and premature birth at times (Feldman et al., 1999).
These complications during childbirth may render the mother physically unavailable to
their child. Due to this, mothers may fail to provide early nurturing and affectionate ma-
ternal bond that is crucial in the building of the child’s psychological resilience (Røseth
et al., 2018).
A mother’s childhood and upbringing has also been identified as a key factor in the qual-
ity of mother-infant bonding. Mothers who have suffered some form of childhood mal-
treatment or emotional neglect during their childhood are more likely to experience an
impaired mother-infant bonding (Lehnig et al., 2019). Other factors such as life pressures
such as a difficult job, joblessness, or financial difficulties may also affect mother-infant
bonding. Life pressures have been known to increase the propensity of after-birth depres-
sion (Goyal, Gay and Lee, 2010; Eastwood et al., 2012). Perceived lack of social support
or difficulty in past pregnancies may also trigger the onset of postpartum depression (Cor-
rigan, Kwasky and Groh, 2015). This unstable emotional state may translate to deferred
affection and feelings of guilt or shame. This then may affect the immediacy of affection
and lead to less than optimal mother-child bonding.
Sometimes difficult child births may result in complications that necessitate a child be
admitted into the NICU. In the NICU, various restrictions that hinder mother-child con-
tact hinder the creation of a bonding connection between mothers and their new-born
babies (Kantrowitz‐Gordon, 2013). Admission of a new-born into the NICU may also
cause devastating and traumatic mental effects on the mother. From this occurrence, their
confidence in child-caring is also shaken and ultimately this may affect how the mother
and child bonds. Reduced interactions between mother and infant may also lead to inad-
equate bonding between the mother and their young one (Phuma-Ngaiyaye and Welcome
Kalembo, 2016). With there being many barriers to the formation of strong mother-infant
bonding and the wide recognition of the importance of this occurrence, there is a need to
14
identify nursing solutions that will bolster formation of strong mother-child bonds at the
NICU.
15
3 THEORITICAL FRAMEWORK
The act of caring is an essential component in nursing and healthcare (Joolaee et al.,
2010). According to Clinton (2014) and NANAP Position Statement (2009), paediatric
nursing is a special type of nursing which focuses on caring for the children and their
families in any health settings. The paediatric nurse also grieves with families as they deal
with disturbing diagnoses, hereditary irregularities, and sudden trauma. Some of the prin-
cipals that reinforce paediatric nursing include the adaptation of care with high respect
for the goals and preferences of each child within the situation of his or her family; en-
couragement of each child/family to contribute in goal setting; provision of all-inclusive
care that is considerate of the physical, spiritual, mental, emotional socio-cultural hered-
itary and developmental aspects of each child/family; and provision of care that is prem-
ised on family centred education, encouragement and active communication. In this chap-
ter we will explore Jean Watson’s, Theory of Human Caring and use it to develop our
study’s theoretical framework.
3.1 Watsons Theory of Human Caring
The Theory of Human Caring by Dr Jean Watson was developed between 1975 and 1979,
while lecturing at the University of Colorado. The theory developed from her own opin-
ions and experiences of nursing, combined, and informed by his doctoral studies in edu-
cational-clinical and social psychology. Originally, Watson attempted to bring meaning
and focus to nursing as an evolving discipline and a separate health profession with its
own unique values, knowledge, and practices, with its own ethic and mission to society
(Gonzalo, 2019).
Through her evolving ideas borne from experiences, practices, nursing values and
knowledge for human caring in her nursing career, she proposed the importance of ap-
proaching nursing like a caring science. Watson emphasized the need of approaching
nursing with empathy and caring, ensuring that nurses make a deliberate effort to exercise
an emotional and open approach to patient care, and that nurses engaged authentically
with patients and their families both at a personal and spiritual level (Savieto and Leão,
2016) Application of Watson’s theory is via what she referred to a carative factors which
16
form the structure of the science of nursing care. Carative factors she posited worked hand
in hand with conventional medicine but stood in stark difference to curative factors (Nel-
son and Watson, 2011).
There are several assumptions that have been identified in Jean Watson’s Theory of Hu-
man Caring. First, this theory emphasizes that caring has a personal nature and can only
be effectively practiced from one person to another. This is what is described as transper-
sonal caring and can be described as the connection of spirits and soul through the process
of trustworthiness in caring for someone of which identifies with a godly union. Nurses
who identifies with this type practice transpersonal caring exhibit a genuine desire to be
available and involved in the relations with patients. Transpersonal nurse focuses on the
mindfulness and reasoning of caring, healing, and fullness, rather than the disease, the
main goal is to help patient attain complete sense of harmony inside the mind, body and
spirit through the process of caring and healing (Savieto and Leão, 2016).
This theory notes that acts that can be classified as caring are those that accept a person
as they are presently as well as how they may be in future. Environments that foster caring
on the other hand are those that offer opportunity for development while allowing people
to chart their own paths that they feel are best for themselves. It is a theory that empha-
sizes the freedom that patients have during care and the role of nurses in respecting these
choices (Watson, 2012).
The theory also notes that within caring are what Watson referred to as carative factors.
It is these factors that result in the satisfaction of certain human needs in patients and
which nurses need to practice in their association with patients. According to (McEwen
and Willis (2011 p.182), ten carative factors have been identified both as stated by Jean
or implicitly identified within her theory based on its assumptions. These are listed in the
figure 1 below. These carative factors emphasize on the need to employ traditional care
practices empathy and strong inter-personal relationships with patients. These carative
factors as espoused by Jean Watson’s theory encourages the utilization of a more emo-
tional and open approach to patients care in healthcare practice. It emphasizes that strong
and helpful interpersonal relationships between a nurse and patient that incorporate
17
emotional and spiritual aspects in nursing care go a long way in promoting general health
and satisfaction.
Jean Watson’s Theory identifies caring to involve: Helping trusting, and caring relation-
ships; Expression of negative and positive feelings; Allowance for existential phenologi-
cal spiritual forces; Teaching-learning; Assisting with basic human needs; Sensitivity to
self and others; Instillation of faith and hope; Formation of humanistic -altruistic system
of values; Supportive and protective all-around environment; and Creative problem solv-
ing.
Figure 1. Watson's Carative Nursing Practices (Watson Theory: Theory of Human Caring, 2020).
3.2 Implication of the Watsons Theory of Human Caring to the
Study.
Watson’s theory of human caring emphasizes the importance of caring in nursing and
identifies it as a foundation for the professional nursing practice. This theory asserts that
in the healing process, individuals cannot be viewed as objects but rather a sum of their
environment. For healing to take place, there must be a personal relationship character-
ized by respect, trustworthiness, and genuine desire to (Savieto and Leão, 2016). Healing
18
also needs that an environment which fosters caring and offers opportunity for people to
be allowed to chart their own paths be present. Nursing has long been categorized as a
humanitarian science, a profession characterized by personal, ethical, and scientific prac-
tice. Watson’s theory of human caring seeks to guarantee harmony between a person’s
health and illness. It emphasizes the need to utilize a holistic approach when providing
care to those who need it. At its core it identifies the mind-body-spirit sub-dimensions
and their importance to a person’s holistic health (Nelson and Watson, 2011).
There are several reasons that makes the Watson’s Theory of Human Caring be a good
fit to guide the direction of this study. First, the theory is people oriented and recognizes
the unique human integrity dimensions without any compromises on a person’s mind,
body, and spirit (Fawcett, 2005 p. 51-59). Secondly, the theory identifies nursing as caring
science characterized by interpersonal relationships, healing, caring and awareness of
healing (Watson, 2012) and finally, the theory has a well delineated caritas process (figure
1) that provides articulate guide to its clinical implementation. Based on this, the study
sought to sought to identify nursing care practices and interventions that support mother-
infant bonding using the Jean Watson’s Theory of Human Caring as a as a framework.
19
4 AIMS AND RESEARCH QUESTION
The aim of this study is to identify the nursing care practices and interventions that nurses
can adopt to facilitate and support the bonding of mothers and their premature infants at
the Neonatal Intensive Care Unit (NICU).
Research question
1. What are the nursing care practices and interventions that nurses can adopt to fa-
cilitate the bonding of mothers and their premature infants at the Neonatal In-
tensive Care Unit (NICU)?
20
5 METHODOLOGY
This study employed a descriptive literature review approach to ascertain the nursing in-
terventions and practices that nurses can adopt to promote mother-infant bonding at the
NICU. In this section, the approach that was used to provide answers to the study’s re-
search questions is laid out. The study’s research design, literature search strategy em-
ployed, and the process used to select relevant studies and undertake full synthesis of
literature is elaborated.
5.1 Data collection
Data collection was undertaken in a sizeable number of peer reviewed scholarly articles
identified from a host of search engines; including the Arcada FINNA, Academic Search
Elite (EBSCO), Cinahl (EBSCO), Cochrane Library, PubMed, Sage, Science Direct, and
Ebrary. Careful selection of keywords relevant to the study was also conducted before the
study began. Keyword selection is central to the thoroughness and accuracy of a literature
review study and any researcher should ensure that they get it right from the start (Grewal,
Kataria and Dhawan, 2016). As such, search terms were selected and used in different
combinations to undertake the search. The search keywords included nursing care, neo-
natal nursing, neonatal nursing intervention, Neonatal Intensive Care Unit (NICU), prem-
ature infant, maternal-infant bond.
To refine the search further it was necessary to apply several refinement filters. First, re-
search papers were only included in the review if they had been published within the
previous 20 years (2000-2019). Publications published earlier than 2000 were also con-
sidered if they were relevant to this study and were available as readable full texts in the
English language.
In addition, the review was centred on using care practice in nursing, specifically with-in
prematurity and mother-baby bonding context at the NICU; literature was therefore ex-
cluded if it fell within other health disciplines. Literature was included if the study was
primarily set at the NICU, the study participants were either mothers of pre-term infants
or NICU nurses, the study identified either negative or positive aspects of nursing care at
the NICU, the study highlighted mothers’ first-hand experiences at the NICU or the study
21
explored the issues at the NICU that either support or derail mother-infant bonding. After
the initial database search was undertaken as described previously in the methodology
section, 203 research publications were returned. On analysing these publications’ con-
tent, 40 were found to be duplicates and were thus excluded. By following the established
inclusion and exclusion criteria, a further 134 publications were removed. Skimming
through the abstracts of all the publications left helped identify publications that were not
relevant to the study and were subsequently removed which remained only 25 articles for
analysis. In appendix 1 below are list of characteristics of the 25 articles reviewed.
5.2 Data Analysis
The study’s aim was to identify the nursing care practices that nurses can adopt in the
Neonatal Intensive Care Unit (NICU) to enhance the formation of mother-infant bond.
Thematic analysis was utilized here with an aim of identifying themes or patterns within
the reviewed studies. The study researchers utilized an inductive content analysis ap-
proach that utilized abstraction to condense and group data into relevant categories that
in turn enabled the researchers to provide answers to the study’s research. The researchers
employed the process outlined by Elo and Kyngäs (2008). This process involves open
coding (inscribing notes, and headings when reading selected text), categorizing (utiliza-
tion of manifest and latent content interpretation to create categories) and abstraction
(crafting of a general description of the study topic). From the major themes observed,
further refinement was conducted to identify specific sub-themes that possessed a con-
nection with the questions this study sought to answer as guided by (Braun and Clarke,
2006). Two major themes were identified with one being the promotion of mother-infant
interactions with the other being the improvement in how mothers and nurses interact at
the NICU, see table 1 below.
22
Table 1. Themes and Sub-themes of Nursing Interventions that Promote Maternal -Infant Bonding at the NICU.
Major Theme Sub-Theme Unit of analysis
Promotion of Mother-In-
fant Interaction
Providing opportunities for
physical contact
7, 10, 11, 19, 20, 21, 23, 25
Providing opportunities for
remote monitoring
13, 22
Providing opportunities for
mothers’ participation in
routine care
5, 9, 15, 21
Mother-Nurse Interac-
tion
Communication 2, 4, 8, 11, 12, 16, 21
Assurance 1, 14, 17, 24
Empathic treatment 3, 15, 18
Exhibiting trustworthiness 3, 6, 10, 21
5.3 Ethical consideration
Contributing to the health evidence base that is then used to guide clinical and policy
decisions requires that study authors make a deliberate effort to ensure that studies are
unbiased, are based on accepted scientific methods and are accurate (Sng, Yip and Han,
2016). One aspect that we sought to achieve was to find most if not all relevant studies to
our research questions to review. Often, most literature databases both electronic and
physical have indexing limitations. It is for this reason that we undertook our literature
search in a variety of repositories to improve the number and quality of relevant research
articles that we were able to identify and utilize in our study. This is because the re-
searchers’ ability to access and utilize appropriate research studies while undertaking a
literature review, goes a long way in influencing the quality of their research (Thomas et
al., 2015). During the preparation of this publication, we the authors also did an in-depth
23
and accurate extraction of studies to be included in this review study. The studies were
extracted independently by the two research authors and any discrepancies that arose were
sufficiently resolved. This approach is crucial and ensures that results are not slant-ed in
any direction and are exhaustive as any relevant study that fit the study’s inclusion criteria
is captured and included (McGowan and Sampson, 2005). The research project was also
undertaken honestly and with integrity. There were no competing interests be they per-
sonal, academic, political, and financial that influenced the direction that we the study
authors took in the synthesis and compilation of this research study. Finally, we the au-
thors tried our best not to duplicate or make redundant copies of past studies. Rather we
sought to provide a unique overview of the nursing interventions that nurses can adopt to
promote mother-infant bonding at the NICU.
24
6 RESULTS
Two major themes were identified from the reviewed literature that sought to identify the
nursing interventions that nurses can adopt to promote mother infant bonding at the
NICU. The first identified theme concerned the promotion of mother-infant interactions,
and the second, mother and nurse interaction in the NICU.
6.1 Promotion of Mother-Infant Interaction
On promotion of mother-infant interaction, there were studies that either highlighted the
importance of physical contact and why nurses should encourage it while others also
showed the beneficial effect that remote contact can have on mother infant bonding.
Breastfeeding (10, 19, 21) and skin to skin contact (Kangaroo Mother Care or KMC) (7,
11, 20, 23, 25) were some of the physical practices that reportedly need to be promoted
by nurses at the NICU.
Remote monitoring such as use of webcams, facetime or even photos (13, 22) was also
shown to possess the ability to reduce mothers’ distress at the NICU and promote mater-
nal infant bonding. Mothers involvement in the routine care of their infants was also iden-
tified as a key contributor to mother infant bonding. On this, practices such as nappy
changing, feeding, repositioning the baby, and being involved in other baby nurturing
activities were found to be essential in the enhancement of baby-infant bond at the NICU
(5, 9, 15, 21).
6.1.1 Providing opportunities for physical contact
There is mounting evidence of how the various forms of mother- infant contact, such as
frequent visitation, skin to skin contact, and even parental talk can result in better bonding
outcomes for infants and their parents during the hospitalization period and beyond. The
importance of skin to skin contact, also, KMC has especially been well studied. While
Kangaroo Mother Care has been associated with positive health outcomes of mothers and
premature infants at the NICU, it has also reportedly been associated with improved
mother-infant bonding and closeness (20).
25
KMC provides a warm, comforting, and calming experience that provides an opportunity
for both mothers and infants to get to know each other (25). Kangaroo care also provides
an opportunity for reciprocal pleasure as well as bond strengthening in an environment
where this could not have happened. During the skin to skin contact moments that char-
acterize Kangaroo care, mothers have in the past reported intense feelings of pleasure and
connectedness that enhanced their feeling of being able to nurture despite the baby’s
prematurity (23).
Skin to skin contact has also been associated with greater emotional closeness between
mother and infant while also enhancing their overall interactions. Mothers who have ex-
perience d separation from their infant at the NICU have also been associated with nega-
tive attachment behaviours that negatively affect the ability to form close bonds with their
infant (7).With the advantages of Kangaroo Care on the infant’s health, mother physical
and psychological condition as well as mother-infant bonding, nurses at the NICU should
provide opportunities for mothers to practice skin to skin care with their infants. This will
go a long way in improving bonding and enhancing the infant’s psychological and phys-
ical resilience going forward.
Breastfeeding is also another form of contact that has been reported to have positive effect
on mother-infant bonding and has been identified as a key activity that nurses in the NICU
should support (21). By initiating early breastfeeding, nurses provided an opportunity for
mothers to bolster the closeness and bonding to their babies and have an experience of
‘motherhood early on’ (19, 21). Breastfeeding may also enhance the formation and en-
hancement of maternal-infant bonding via the promotion of maternal nurturing compe-
tency which aids alleviation of emotional distress in mothers and supports the bonding
process (10, 21). It is for this reason that nurses and NICU attendants should encourage
breastfeeding of infants by their mothers if possible, at the NICU.
6.1.2 Providing opportunities for remote monitoring
The NICU setting brings about many psychosocial disruptions and physical limitations
that separates infants from their mothers, ultimately affecting the bonding of infants to
their mothers. The emphasize made of the importance of photographs in enhancing
26
closeness between mother and their infant observes that photos provide rehearsed mem-
ories of an infant’s life to their mother and help parents cope with the situation by observ-
ing the improvement in health and size of their infant (13).
Use of technology that enables a mother to monitor their child at the NICU has also been
identified as an effective way of breaking the separation barrier between mother and in-
fant and promoting proximity. Facetime, a technology with the ability to provide live
video feed, was used by mothers to monitor their babies at the NICU with great success.
This technology reduced time taken by mothers to see their babies for the first time and
worked to reduce anxiety and worries that the mother had of their child condition as they
were able to view their baby and talk to a nurse about their condition. This improved
proximity not only provided assurance to the mother but also enhanced the maternal-
infant bond (22).
Utilizing technology to improve a mother’s proximity to her baby seems like a viable
route that nurses can utilize in the NICU to both reduce anxiety and fears of the mothers
as well as support mother-infant bonding (13, 22).
6.1.3 Providing opportunities for the participation in routine care
An enabling environment that empowers mothers to directly participate in the care of
their babies has also been identified as a key component of enhancing mother-infant
bonds at the NICU (21). Routine care of the infant involves nurturing actions that may
include comforting, talking to, singing to, and touching the baby. Others include turning
the infant, changing their nappies, feeding, and responding to their actions. Participating
in care by mothers at the NICU has known health and psychological benefits to infants at
the NICU. It has also been associated with reduced maternal anxiety and improved
mother-infant bonding (5).
It has reported that women who were involved in the care of their infants at the NICU
experienced the feelings of confidence and connection to their infants. They also felt more
competent to handle their babies an action that improved their emotional competence
(15). It is in order that nurses have a duty to restrict the infant access if its detrimental to
27
their health, however, nurses should do their best to actively involve parents in the care
of their infants of they are to empower them a key players in the infants care (9).
6.2 Mother-Nurse Interaction
Mother-nurse interactions also featured prominently in the list of interventions that can
support mother-infant bonding. Communication that was effective, constant, consistent,
empathetic, warm, positive, and symmetrical was reported to reduce psychosocial dis-
tress, enhance maternal competence, and promote mother-infant bonding. Psychosocial
support in form of assurance, empathetic treatment and exhibition of trustworthiness were
also essential in the promotion of mother infant bonding at the NICU (1, 2, 3, 4, 6, 8, 10,
11, 12, 14, 15, 16, 17, 18, 21, 24).
6.2.1 Communication
Communication when conducted effectively between nurse and patients remain a central
element of supportive care as anchored in the family-centred care (FCC) philosophy. In
this research, there was a general agreement between (8, 2, 4 and 21) that appropriate and
effective communication between the NICU nurse and the infant’s mother could facilitate
mother-premature infant bonding. From their studies, the authors described appropriate
communication that supports mother-premature infant attachment as one which includes
chatting: talk that is majorly on general issues and treads away from the infants condition,
involves the nurses asking mothers questions and is characterized by nurses informing
mothers of their availability for any clarification, question or contention. The authors
noted that nurses who adopted an emotional way of expressing themselves that was caring
and reassuring and demonstrated empathy and warmth were able to communicate effec-
tively with mothers of premature infants and were able to build relationships that were
supportive with the mothers. This ultimately provided a great environment which encour-
aged mothers to bond with their babies. Mothers at the NICU often encounter nurses who
are poor communicators, disrespectful and even rude an aspect that increases the anxiety
of new mothers while discouraging them to ask questions or seek assurance (12). On the
other hand, clear, effective, and positive communication empowered mothers and im-
proved their participation in active care of their infant (12).
28
A key theme that was highlighted by these studies was that supportive relationship be-
tween nurses and infants’ mothers needed to be symmetrical and to exhibit a balance of
power (2, 4, 8, 11, 16, 12). When the communication exhibited an asymmetrical nature
and was nurse-led, a potential psychological barrier that hurt the communication fluency
was created (16). The ineffective communication that ensued, ultimately, hindered the
attachment and bonding of mother and infant (16).
6.2.2 Assurance
In a cross-sectional study that interviewed mothers who had infants at the NICU at five
Riyadh city hospitals reported that assurance ranked very highly in the needs of mothers
with children at the NICU. Mothers, the researchers noted, need reassurance that their
children were responding well to treatment, were receiving the highest quality of care and
that their situation was improving (1). The importance of assurance to mothers and fathers
at the NICU was also reported in a descriptive cross-sectional study that involved inter-
viewing mothers, fathers and nurses, the authors found that the need for assurance of the
child’s status and quality of care they are receiving was one of the key needs of a prema-
ture infant’s parents. This study emphasized the needs for nurses to provides assurance to
such parents to reduce their anxiety, stress, and fears (17).
Also, another study reported that of 56 needs that parents at the NICU needed, in their
evaluation of perceived needs identified assurance as a key need which ranked the highest
and the first in the needs ranking of families with children at the NICU (24). Mothers at
the NICU suffer significant post-traumatic stress, anxiety, anger, powerlessness, negative
feelings and even depression which can affect how a mother and child interact early on
and interfere with the all-important mother-infant bonding. Provision of assurance to
mothers has been reported as a key stress and anxiety modulators of mother at the NICU
(14, 24, 17, 1).
29
6.2.3 Empathic treatment
Owing to the apparent psychosocial support needs, it is no wonder that several studies
have highlighted ways that nurses can provide psychosocial support to mothers of prem-
ature infants at the NICU to support their emotional competence. One way that nurses
can support mothers of premature infants at the NICU is by undertaking empathic treat-
ment during nursing care at the NICU. This can be in the form of explicit consolations,
provision of encouragement and hope, employment of an empathic tone during commu-
nication, holding conversations about mothers’ feelings and even through providing pos-
itive attention to them (3). These assertions are also validated by other researches who
have also identified that when a mother-nurse relationship characterized by constant en-
couragement, guidance, and emotional support is created at the NICU, mothers ability to
cope is strengthened and their emotional distress is reduced (15, 18).
6.2.4 Exhibition of trustworthiness
Often, mothers at the NICU identified that nurses who accurately and thoroughly in-
formed them of their child status, medical procedure they are undergoing was the key to
alleviate their emotional distress (3). Mothers according to study were glad when nurses
answered questions asked clearly, consistently and in a non-contradictory manner even
without the mothers asking. When nurses employed a very trustworthy stance in their
interactions with mothers, mothers’ emotional distress was alleviated and their trust in
the medical staff and system was restored (3, 21). Another study also supports this asser-
tion noting that, when nurses are upfront with information, are open, non-judgmental, and
supportive, a trust-worthy relationship is created between them and the mother. Creation
of these trustful bonds then results in improvement in mothers’ self-esteem and emotional
stability (10). This ultimately translates to better competence in mother-baby interaction
and bonding. On trustworthiness at the NICU then, nurses need to be exhibit friendliness,
consistency and initiative in sharing information and adopt a non-judgmental stance in
their interactions with mothers if they are to improve mothers’ confidence, reduce their
emotional distress and improve their maternal competence in their interaction with their
infants (6).
30
7 DISCUSSION
The aim of this study is to identify the nursing care practices and interventions that nurses
can adopt to facilitate and support the bonding of mothers and their premature infants at
the Neonatal Intensive Care Unit (NICU). The discussion of the findings is in relation to
the reviewed articles and Watson Theory of Human Caring.
7.1 Discussion in relation to the literature
One aspect that was mentioned widely was the importance of mother-premature infant
contact in promoting bonding and the importance of nurses as facilitators. This is no sur-
prise because prematurely born infants often require hospitalization in the NICU a situa-
tion that brings about a forced separation between the mother and infant. Often these
separations may last weeks or even months and ultimately may affect the all-important
mother-infant closeness and bonding (Flacking et al., 2012). Most parents with infants at
the NICU have constantly told of their desire to hold, touch or be in contact with the baby
(Lindberg and Öhrling, 2008) and always describe it as a highly rewarding and important
moment in their motherhood. Nurses have long been identified as either facilitators or
facilitators to this contact and with evidence pointing to the importance of mother-infant
contact in promotion of mother-infant bonding, nurses need to play a greater role as fa-
cilitators of this contact.
Nurses need to encourage of skin to skin contact, providing opportunities for mothers to
breastfeed their infants and even involving mothers more in the care of their children to
enhances the mother- infant interaction. However, the participation of mothers in the care
is only possible if mothers allow it. Often, nurses are gatekeepers that oversee the parents’
access to their infants (Gibbs, Boshoff and Stanley, 2015). Kangaroo care involves the
skin‑to‑skin contact of mother and infant usually by placing an infant naked upright on
her mother’s bare chest (Cattaneo et al., 2018). Also, contact brought about by breast-
feeding is crucial in the mother-infant bonding early on. This is not only from the nurtur-
ing nature of breastfeeding but by the neurochemicals released during the process that
enhance mother-infant bond (Buckley, 2015). A mother’s voice has been reported to im-
prove an infant’s neurofunction, feeding behaviour, visual attention, growth as well as
31
the vocalization of the infant (Caskey, Stephens, Tucker and Vohr, 2011; Filippa et al.,
2013).
The participation of mothers in care is only possible if mothers allow it. Often, nurses are
gatekeepers that oversee the parents’ access to their infants (Gibbs, Boshoff and Stanley,
2015). Contact between the mother does not need to be skin to skin all the time, other
forms of contacts such as visual contact, vocalizations, touch as well as use of technology
have been associated with the enhancement of the mother-child relationship and closeness
(Flacking et al., 2012). This can be in the form of providing opportunities for remote
monitoring, Ultimately, this practice has improved their confidence as mothers and im-
proved their emotional availability to their premature infant (Feldman, Weller, Sirota and
Eidelman, 2002). The act of remote monitoring of infants by their mothers is also sought
to determine the effect of using the webcam technology as a monitoring tool for mothers
with children at the NICU. The author reported that there was a reduction in stress and
anxiety symptoms after mothers viewed their babies via a webcam. There was also an
improvement in their emotional closeness to the baby. There was however widespread
agreement that the remote monitoring opportunity would not wholly substitute physical
viewing and touch. Care should also be taken, however, to ensure that this intervention is
not substituted wholly with physical contact and attention (Rhoads, Green, Mitchell and
Lynch, 2015).
Effective communication between an infant’s parent and the nurse at the NICU may go a
long way in relieving stress, reducing anxiety, and managing fears. In the NICU environ-
ment, however, instances of miscommunication, ineffective communication or even lack
of communication are rampant (Reid, Bramwell, Booth and Weindling, 2007). Because
parental stress affects attachment, bonding and communication on the other hand exacer-
bates stress and anxiety, there is a need for improvement in how nurses communicate with
mothers of premature at the NICU. Communication by nurses to mothers need to be con-
stant, consistent, empathetic, warm, positive, and symmetrical if it is to reduce psychoso-
cial distress, enhance maternal competence and promote mother-premature infant bond-
ing.
32
Assurance was a practice that nurses were encouraged to adopt in their quest to promote
mother-infant bonding at the NICU. Mothers need constant assurance from nurses that
their infant is being provided with the best care, is being treated for pain, and that nurses
and doctors care about the baby and are doing everything in their power to improve the
health of their baby. If assurance is provided adequately, mothers’ stress levels are re-
duced and their ability to interact with their premature infant at the NICU is bolstered
(Feeley et al., 2016). Assurance therefore is an aspect that nurses should adopt in their
care of mothers and their premature infants at the NICU.
The issue of empathetic treatment of mothers at the NICU and its role in promoting
mother infant bonding at the NICU has also been highlighted expansively in literature.
At the NICU, mothers often suffer from a host of physiological disorders that include
stress, anxiety, guilt, hopelessness, as well as loss of control (Obeidat, Bond and Callister,
2009). Most of the time, this emotional distress mothers experience here are severe
enough to pass the posttraumatic stress or acute stress disorder diagnostic criteria (Lefko-
witz, Baxt and Evans, 2010). This is often caused by the nature of experiences at the
NICU where the role of the infant’s mother is altered, and the appearance and behaviour
of the infant is fear inducing (Busse, Stromgren, Thorngate and Thomas, 2013). Mothers
psychosocial distress always result in worse outcomes in their health, their ability to in-
teract with infant and family as well as the infant’s future cognition and behaviour (Grun-
berg, Geller, Bonacquisti and Patterson, 2018). It is for the above psychosocial support
needs that that the importance of psychosocial support and empathetic treatment of moth-
ers in NICU by nurses comes to the fore.
Another form of psychosocial support that nurses can extend to mothers of premature
infants in their care is by exhibiting trustworthiness in their interactions. Mothers need
their questions answered clearly, consistently and in a non- contradictory manner even
without the mothers asking. Formation of a trustworthy relationship between a nurse and
a mother at the NICU improves the mother’s emotional stability, and self-esteem and
provides an opportunity for mothers to be emotionally available to care for their children
(Phuma-Ngaiyaye and Welcome Kalembo, 2016). Nurses at the NICU therefore have an
important role to play in forging trustworthy relationships with mothers at the NICU if
they are to assist mothers and their infants’ bond effectively.
33
7.2 Discussion in relation to Watson Theory of Human Caring
From our findings, we identified promotion of mother-infant interactions activities such
as routine child care, breastfeeding and skin to skin contact (Kangaroo care), providing
opportunities for remote monitoring as well as enhancing mother-nurse interactions at the
NICU by improvement of mother-nurse communication, provision of necessary psycho-
social support to distressed mother and being a trustworthy companion at the NICU.
(Flacking, Ewald, Nyqvist and Starrin, 2006; Fegran, Fagermoen and Helseth, 2008;
Cockcroft, 2012; Phuma-Ngaiyaye and Welcome Kalembo, 2016; Bry and Wigert, 2019)
as being crucial to the promotion of mother-infant bonding at the NICU. All these actions
and activities depict the creation of caring moments where the nurse and the mothers at
the NICU come together regardless of their unique life histories and beliefs in a human-
to-human transaction as envisioned by Watson as his penned the theory of caring.
One key aspects of Watson’s theory that has vividly come to light with this research is
the concept of transpersonal caring, which is a major theme in Watson’s theory of caring.
Watson (2012) describes a transpersonal nurse as one who “has the ability to focus con-
sciousness and intentionality on caring, healing, and wholeness, rather than on disease,
illness and pathology”; Transpersonal caring focuses on helping patients achieve a more
complete sense of harmony within the mind, body and spirit through the use of caring
transactions. Transpersonal caring seeks to connect with and embrace the spirit or soul of
the other through the processes of caring and healing and being inauthentic relation, in
the moment (Savieto and Leão, 2016). In the present study, there was a host of transper-
sonal caring actions by nurses that were identified to be crucial in the promotion of mother
infant bonding. Actions such as providing psychosocial support and assurance, providing
encouragement and hope, providing mothers with opportunity-ties to interact with their
mothers, creating trustful relationship with mothers and being present and attentive to
mothers overall needs to ensure they attain a higher degree of harmony in their minds,
bodies and souls. This is all in line with Watson’s theory of human caring and goes a long
way to cement the importance of the utilization of the human caring framework by nurses
in their interactions with patients. The caring model or theory can be considered a philo-
sophical and moral/ethical foundation for professional nursing and part of the central fo-
cus for nursing at the disciplinary level. As a model of caring, it offers a framework that
34
embraces and intersects with art, science, humanities, spirituality, and is now becoming
a central phenomenon of nursing practice (Gonzalo, 2019). Nurses who embrace caring
in their work have success in promoting the body, mind, and soul healing of those they
are caring for (Fenwick, Barclay and Schmied, 2008). As such, we note that nurses work-
ing in neonatal intensive care units need to develop nursing care practices which are not
only grounded upon a well-established theoretical framework but also work to support
mother infant bonding. In corporation Watson’s caring approach in nursing may therefore
be one step towards promoting mother infant bonding at the NICU.
35
8 CONCLUSION
As revealed in this current study, the nursing care practices that can be employed in the
neonatal intensive care units by nurses to promote mother-infant bonding include provid-
ing opportunities for mother-infant contact such as kangaroo care and breastfeeding,
providing psychosocial support, effective communication, consistent information dissem-
ination, provision of feedback and assurance, empathetic treatment of mothers the NICU,
being trustworthy and involving mothers in the care of their infants.
The research findings also indicate that the mother-infant bonding process is not always
automatic and that the nature of the NICU environment complicates this attachment pro-
cess. This justifiably indicates that attainment of mother-infant bonding requires facilita-
tion by health personnel at the NICU, especially, the NICU nurse. The NICU nurse, the
study highlighted, possesses the power to either promote or hinder the mother-infant at-
tachment and bonding process. Because there is evidence that early mother-infant bond-
ing is essential for an infant’s neurological development process, nurses should take the
role of facilitating this attachment process from birth seriously.
8.1 Strengths and limitations
This study faced several limitations. First, some useful scientific articles which are related
to the study could not be accessed at the Arcada databases. Second, twenty research arti-
cles were expected to be selected in the beginning of data collection phase, which proved
very difficult to find appropriate articles for the research topic or to respond the research
question which affected time frame expected to accomplish this study. Thirdly, this study
is limited by not getting enough but a more suitable literature for review. Notwithstand-
ing, as has been reiterated earlier on, those selected previous literatures are equally im-
portant and applicable in this case since the purpose and corresponding findings in the
end produced some suitable answers directly or indirectly to the research question. Hence,
these identified limitations do not pose any major threat to the out-come of the study.
36
8.2 Recommendations for future studies
We recommend a similar but an in-depth research into this important and interesting topic
by focusing on using primary data with questionnaire specifically designed to answer
those research questions raised through a structured or semi-structured interview. In this
way we believe a stronger and probably a more concrete result may be produced for a
more informed conclusion to be drawn.
Also, another future research can also be conducted to investigate the bond and relation-
ship the nurses establish with the preterm babies at the NICU since the nurse spend more
time taking care of them than their respective parents.
37
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593.
40
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APPENDIX 1 CHARACTERISTICS OF THE ARTICLES REVIEWED
Article 1: Alsaiari, E. M., Magarey, J. and Rasmussen, P., 2019, An Investigation of the
Needs of Saudi Parents of Preterm Infants in the Neonatal Intensive Care Unit”, Cureus.
11(1), pp. e3887-e3887.
Aim: “to identify the needs of Saudi parents who had an infant in a neonatal intensive
care unit (NICU) in one of five hospitals in Riyadh City, Saudi Arabia”
Method: Questionnaire
Relevant results to the research: Assurance was ranked the most important needs by
parents as to comfort and other supporting needs.
Article 2: Bialoskurski, M., Cox, C. and Wiggins, R., 2002. The relationship between
maternal needs and priorities in a neonatal intensive care environment. Journal of Ad-
vanced Nursing, 37(1), pp.62-69.
Aim: “to investigate the nature and organization of maternal needs and priorities in a
neonatal unit”
Method: Quantitative survey based on 209 mothers with premature infants and the data
were analysed with multivariate analysis.
Relevant results to the research: Good communication practices with professionals
were valued by mothers with premature babies.
Article 3: Bry, A. and Wigert, H., 2019. Psychosocial support for parents of extremely
preterm infants in neonatal intensive care: a qualitative interview study. BMC Psychol-
ogy, 7(1).
Aim: “exploring the needs of psychosocial support of parents of extremely premature
infants, and how the NICU as an organization and its staff meets or fails to meet these
needs”
Method: Open-ended interviews were conducted with 27 parents after their infant's dis-
charge from the NICU and inductive content analysis was performed.
Relevant result to the research: Parents of premature infants needed various forms of
emotional support at the NICU, including support from staff, professional psychological
help, and companionship with other patients’ parents. Parents were willing to share their
emotional state with staff.
Article 4: Cockcroft, S., 2012. How can family centred care be improved to meet the
needs of parents with a premature baby in neonatal intensive care?. Journal of Neonatal
Nursing, 18(3), pp.105-110.
Aim: “to identify areas of practice that reflect a family centred care (FCC) approach when
a baby is born prematurely”
Method: A descriptive design
Relevant result to the research: Involvement of family in the planning, implementation,
and decision-making process- family centred care (FCC). Giving access of information
to family and providing feedback.
Article 5: Fancourt, D. and Perkins, R., 2018. The effects of mother–infant singing on
emotional closeness, affect, anxiety, and stress hormones. Music & Science, 1,
p.205920431774574.
Aims: “to understand the impact of maternal singing on mother-infant bonding and
looked to explore specifically the effect of a short period of singing on in-the-moment
self-perceptions of mothers as to how they felt themselves and in relation to their infants”
Method: A within-subject crossover design was employed and was analysed using SPSS
version 23.0
Relevant result to the research: Mother-infant singing has greater positive effect on
both psychological and biological signs of anxiety.
Article 6: Fegran, L., Fagermoen, M. and Helseth, S., 2008. Development of parent-nurse
relationships in neonatal intensive care units - from closeness to detachment. Journal of
Advanced Nursing, 64(4), pp.363-371.
Aims: “to explore the development of relationships between parents and nurses in a ne-
onatal intensive care unit”
Method: A hermeneutic approach using overt participant observation (160 hours) and in-
depth interviews to study interactions between parents and nurses.
Relevant result to the research: Provision of trustful relationship, instilling confidence
into parents and allowing parents participation. Acknowledging the need of parent-nurse
discussion of processes of involvement.
Article 7: Feldman, R., Weller, A., Leckman, J., Kuint, J. and Eidelman, A., 1999. The
Nature of the Mother's Tie to Her Infant: Maternal Bonding under Conditions of Proxim-
ity, Separation, and Potential Loss. Journal of Child Psychology and Psychiatry, 40(6),
pp.929-939.
Aims: “centred on mothers' post‐partum thoughts and behaviours: maternal bonding was
examined under conditions of closeness, separation, and potential loss”
Method: Interviews
Relevant results to the study: Attachment behaviours such as anxiety and depression
were perceived the highest traits during the mother-infant separation.
Article 8: Fenwick, J., Barclay, L. and Schmied, V., 2001 “Chatting”: an important clin-
ical tool in facilitating mothering in neonatal nurseries, Journal of Advanced Nursing,
33(5), pp.583-593.
Aims: “to explores the use of 'chat' or 'social talk' as an important clinical tool that can
assist nurses achieve family-centred care in neonatal nurseries”
Method: A grounded theory analysis of over 60 hours of interview data with 28 women,
a thematic analysis of 50 hours of interviews with 20 nurses and a content analysis of 398
tape-recorded interactions between nurses and parents.
Relevant result to the study: The nursing act as a facilitator that helps in instilling con-
fident and assisting parents to connect in caring for their infants in the neonatal wards.
Article 9: Fenwick, J., Barclay, L. and Schmied, V., 2008. Craving closeness: A
grounded theory analysis of women's experiences of mothering in the Special Care
Nursery. Women and Birth, 21(2), pp.71-85.
Aims: “to increase knowledge and understanding of how women begin their roles as
mothers when their infant is in the neonatal nursery”
Method: In-depth interviews conducted with 20 women of whom 19 were midwives,
333h of taped cot side recordings and field notes.
Relevant results to the study: Allowing physical contact with their premature baby is a
good approach through which mothers learn about and gain intimate knowledge of their
infant, but also exhibit authority and ownership.
Article 10: Flacking, R., Ewald, U., Nyqvist, K. and Starrin, B., 2006. Trustful bonds: A
key to “becoming a mother” and to reciprocal breastfeeding. Stories of mothers of very
preterm infants at a neonatal unit. Social Science & Medicine, 62(1), pp.70-80.
Aims: “to explore how mothers of very preterm infants experienced the breastfeeding
process emotionally and how this related to the process of becoming a mother, from the
time before the infants’ birth until discharge from the neonatal unit”
Methods: A qualitative study, inspired by the grounded theory approach, in-depth inter-
views were conducted with 25 mothers whose very preterm infants had been cared for in
seven NICUs in Sweden.
Relevant result to the study: The provision of nursing support in helping mothers to
breastfeed their premature infants in a favourable manner to enhance the bonding and
confidence.
Article 11: Hopwood, R., 2010, The role of the neonatal nurse in promoting parental
attachment in the NICU, Infant, 6(2), pp.54-58.
Aims: “examining how attachment is affected in NICU, and specific methods of how it
can be facilitated through positive touch and communication techniques”
Method: A descriptive study
Relevant result to the research: The nursing relationship between the mother and the
premature infant can lead to a negative outcome if the quality of nursing care does not
meet the needs of the parents. So therefore, the nurse plays a unique role in facilitating
the positive attachment by allowing skin to skin contact, consistent flow of communica-
tion, appropriate support m which contribute to the wellbeing of the infants and conform-
ing with the FCC.
Article 12: Horwood, C., Haskins, L., Luthuli, S. and McKerrow, N., 2019. Communi-
cation between mothers and health workers is important for quality of newborn care: a
qualitative study in neonatal units in district hospitals in South Africa. BMC Pediatrics,
19(1).
Aims: What is the importance of communication between mums and health workers at
the NICU?
Method: An observational qualitative case study approach
Relevant to the research: Good communication between health workers and mothers,
empowering mothers to take control and good communication at the NICU is a necessity
for a child and mothers wellbeing.
Article 13: Huckabay, L. M., 1999. Impact of a research study a decade later: the use of
pictures in a neonatal intensive care unit as a mode of nursing intervention to enhance
maternal-infant bonding. Scholarly Inquiry for Nursing Practice, 13(4), pp. 367-373.
Aims: “to determine if they provide mothers the pictures of their premature babies as part
of their nursing intervention to facilitate maternal-infant bonding”
Methods: Interviews
Relevant to the research: Photos provide rehearsed memories of an infant’s life to their
mother and help parents cope with the situation by observing the improvement in health
and size of their infant.
Article 14: Ionio, C., Mascheroni, E., Colombo, C., Castoldi, F. and Lista, G., 2019.
Stress and feelings in mothers and fathers in NICU: identifying risk factors for early in-
terventions. Primary Health Care Research & Development, 20.
Aims: “the aims of this study were to explore parents’ stress levels and negative feeling
after premature births and to identify the risk factors related to parents’ stress and negative
feelings during their children’s neonatal intensive care unit (NICU) stay”
Methods: 43 mothers and 38 fathers of preterm infants filled out the Parental Stressor
Scale.
Relevant to the study: The NICU might be a stressful place parents but early identifica-
tion of these risk immediately after their children are born could help to direct specific
interventions that can reduce these parents’ stress and prevent them from negative feel-
ings.
Article 15: Johnson, A., 2008. Promoting Maternal Confidence in the NICU. Journal of
Pediatric Health Care, 22(4), pp.254-257.
Aims: “to discuss the attributes of maternal-infant attachment, examine the challenges
the NICU environment presents, and propose nursing interventions that facilitate and sup-
port the development of maternal confidence in the NICU”
Method: Descriptive research design
Relevant to the research: Allowing parent to partake in the care of their premature create
an environment that facilitates maternal-infant attachment by offering mothers positive
experiences.
Article 16: Jones, L., Woodhouse, D. and Rowe, J., 2007. Effective nurse parent com-
munication: a study of parents’ perceptions in the NICU environment. Patient Education
and Counselling, 69(1–3), pp.206-212.
Aims: “to examined mothers’ and fathers’ perceptions of effective and ineffective com-
munication by nurses in the neonatal intensive care unit (NICU) environment, using com-
munication accommodation theory (CAT) as the framework”
Method: 33 parents participated in a semi-structured interview and the interviews were
coded using the CAT strategies.
Relevant to the research: Effective communication by nurses was accommodating and
more social while ineffective communication was generally under-accommodative and
more intergroup.
Article 17: Ladani, M. T., Abdeyazdan, Z., Sadeghnia, A., Hajiheidari, M. and Hasanza-
deh, A., 2017. Comparison of Nurses and Parents’ Viewpoints Regarding the Needs of
Parents of Premature Infants in Neonatal Intensive Care Units. Iranian Journal of Nursing
and Midwifery Research, 22(5), pp.367-371.
Aims: “to compare the parents' and nurses' viewpoints regarding parents' needs in the
neonatal intensive care units (NICU)”
Method: Questionnaires
Relevant to the research: The need for assurance of the child’s status and quality of care
they are receiving was one of the key needs of a premature infant’s parents.
Article 18: Mok, E. and Leung, S., 2006. Nurses as providers of support for mothers of
premature infants. Journal of Clinical Nursing, 15(6), pp.726-734.
Aims: “to explore the supportive behaviour of nurses as experienced by mothers of prem-
ature infants in Hong Kong”
Method: 37 mothers in a regional hospital NICU filled the ‘Nurses Parent Support Tool’
(NPST) which consists of four aspects: communication information support, emotional
support, parental esteem support and quality care‐giving support of which 6 mothers were
interviewed after the completion of the tool to give examples of supportive and non‐sup-
portive behaviour.
Relevant to the research: Nurses must adapt to ways to offer support of encouragement,
hope and so on to parents of premature infants.
Article 19: Obeidat, H. M., Bond, E. A. and Callister, L. C., 2009, The parental experi-
ence of having an infant in the new-born intensive care unit, The Journal of Perinatal
Education, Springer, 18(3), pp.23-29.
Aims: “to explore and describe the experience of parents with an infant in the new-born
intensive care unit (NICU)”
Method: A systematic literature review describing parental experiences that were evalu-
ated and themes were identified.
Relevant to the research: Nursing interventions that promote positive psychosocial out-
comes such as KMC, breastfeeding is needed to decrease parental feelings of stress, anx-
iety, and loss of control.
Article 20: Parsa, P., Karimi, S., Basiri, B. and Roshanaei, G., 2018. The effect of kan-
garoo mother care on physiological parameters of premature infants in Hamadan City,
Iran. Pan African Medical Journal, 30.
Aims: “to evaluate the effect of Kangaroo Mother Care (KMC) on physiological param-
eters of premature infants in Fatemiyeh Hospital in Hamadan in 2016”
Method: A quasi-experimental design (one experimental and one control group with 100
patients)
Relevant to the research: Introduction of Kangaroo care in NICU setups has the poten-
tial of improving both the wellbeing of the mother and premature baby.
Article 21: Phuma-Ngaiyaye, E. and Welcome Kalembo, F., 2016. Supporting mothers
to bond with their newborn babies: Strategies used in a neonatal intensive care unit at a
tertiary hospital in Malawi. International Journal of Nursing Sciences, 3(4), pp.362-366.
Aims: “to investigate the strategies for supporting maternal–new-born bonding for moth-
ers whose neonates were admitted to an intensive care unit at a tertiary hospital in Ma-
lawi”
Method: An explorative qualitative design consisting of 10 mothers and five nurses/
midwives). In-depth interviews and audio recordings were collected.
Relevant to the research: Mother new-born interaction (breastfeeding and maternal in-
volvement in baby care) and mother nurse/midwife interaction (effective communication
and psychological support.
Article 22: Psychogiou, K., Ashworth, C., Weaver-Lowe, L., Carroll, C., Callow, C. and
Edi-Osagie, N., 2020. Novel use of Facetime in supporting maternal-infant bond-
ing. Journal of Neonatal Nursing, 26(2), pp.106-108.
Aims: “to explore the use of technology assisted communication, describe our experi-
ence, and make recommendations for its future development and use in neonatal units”
Method: A cross-sectional survey conducted between December 2014 and February
2015, which used pre and post intervention questionnaire.
Relevant to the research: The use of technology can be an intervention that allows tech-
nology to provide reassurance and promotes bonding between maternal and their new-
born which supports the use of telemedicine systems.
Article 23: Tessier, R., Cristo, M., Velez, S., Giron, M. et al., 1998, Kangaroo mother
care and the bonding hypothesis, Pediatrics, United States, 102(2), p. e17.
Aims: “the purpose of this study was to examine the relationship between intervention
with Kangaroo” Mother Care (KMC) and the subsequent mental development of the in-
fants”
Method: A randomized controlled trial conducted of 488 infants weighing <2001g, with
246 in the KMC group and 242 in the traditional care (TC) group.
Relevant to the study: KMC creates a climate where parents become progressively more
aware of the baby and more prone to sensitive caring. It allows developmentally optimal
care in which parents are helped to ‘manage’ their biological parenting abilities and pro-
motes the cooperation between nurses and parents.
Article 24: Vaškelytė, A., Butkevičienė, R. and Klemmac, D., 2009. Assessing needs of
families with premature newborns in the Neonatal Intensive Care Unit. Medicina, 45(4),
p.320.
Aims: “to identify needs of families with premature new-born’s in the Neonatal Intensive
Care Unit, perceived by parents and nurses”
Method: The NICU Family Needs Inventory was used for data collection. The instrument
included five dimensions of needs. Reliability of the scale was identified as 0.94 using
Cronbach’s.
Relevant to the research: Assurance emerge as the most important need of the parent as
to comfort that was perceived as the least important by parents and nurses.
Article 25: Wigert, H., Johansson, R., Berg, M. and Hellstrom, A., 2006. Mothers' expe-
riences of having their newborn child in a neonatal intensive care unit. Scandinavian
Journal of Caring Sciences, 20(1), pp.35-41.
Aims: “to describe mothers’ experiences when their full‐term new-born child was cared
for in a NICU during the postpartum maternity care period”
Method: A phenomenological hermeneutic interview study. 10 mothers were inter-
viewed once, 6 months to 6 years after the experience.
Relevant to the research: Kangaroo Mother Care has been associated with positive
health outcomes of mothers and premature infants at the NICU, it has also reportedly been
associated with improved mother-infant bonding and closeness.
